[Senate Hearing 117-196]
[From the U.S. Government Publishing Office]
S. Hrg. 117-196
ADDRESSING DISPARITIES
IN LIFE EXPECTANCY
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING DISPARITIES IN LIFE EXPECTANCY, AFTER RECEIVING TESTIMONY
FROM KATHLEEN MULLAN HARRIS, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL;
WILLIAM E. COOKE, FOUNDATIONS FAMILY MEDICINE, AUSTIN, INDIANA; AND BOB
MACKENZIE, KENNEBUNK POLICE DEPARTMENT, KENNEBUNK, MAINE
__________
JULY 21, 2021
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
46-776 PDF WASHINGTON : 2023
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
------
SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY
BERNIE SANDERS (I), Vermont, Chairman
ROBERT P. CASEY, JR., Pennsylvania SUSAN M. COLLINS, Maine, Ranking
TAMMY BALDWIN, Wisconsin Member
CHRISTOPHER S. MURPHY, Connecticut RAND PAUL, M.D., Kentucky
TIM KAINE, Virginia LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire ROGER MARSHALL, M.D., Kansas
JACKY ROSEN, Nevada TIM SCOTT, South Carolina
BEN RAY LUJAN, New Mexico JERRY MORAN, Kansas
PATTY MURRAY, Washington (ex BILL CASSIDY, M.D., Louisiana
officio) MIKE BRAUN, Indiana
RICHARD BURR, North Carolina (ex
officio)
C O N T E N T S
----------
STATEMENTS
WEDNESDAY, JULY 21, 2021
Page
Committee Members
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Retirement Security, Opening statement..................... 1
Collins, Hon. Susan, Ranking Member, a U.S. Senator from the
State of Maine, Opening statement.............................. 3
Witnesses
Mullan Harris, Kathleen, Ph.D., James E. Haar Distinguished
Professor of Sociology, University of North Carolina, Chair,
Committee on Rising Midlife Mortality Rates and Socioeconomic
Disparities, The National Academies of Sciences, Engineering,
and Medicine, Chapel Hill, NC.................................. 5
Prepared statement........................................... 8
Cooke, William, E., M.D., FAAFP, FASAM, AAHIVS, Owner and Medical
Director, Foundations Family Medicine, Austin, IN.............. 21
Prepared statement........................................... 23
MacKenzie, Robert, F., Chief of Police, Kennebunk Police
Department, Kennebunk, ME...................................... 25
Prepared statement........................................... 26
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
The Two Trajectories of Life................................. 37
Confornting a Legacy of Scarcity: A Plan for America's Re-
Investment in Public Health................................ 38
Community Health and Economic Prosperity, Engaging Businesses
as Stewards and Stakeholders--A Report of the Surgeon
General.................................................... 72
Addressing Social Determinants of Health in Primary Care,
Team-Based Approach for Advancing Health Equity............ 431
QUESTIONS AND ANSWERS
Response by Kathleen Mullan Harris to questions of:
Senator Casey................................................ 443
Response by Robert F. MacKenzie to questions of:
Senator Casey................................................ 444
ADDRESSING DISPARITIES
IN LIFE EXPECTANCY
----------
Wednesday, July 21, 2021
U.S. Senate,
Subcommittee on Primary Health and Retirement Security,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10 a.m., in
room 430, Dirksen Senate Office Building, Hon. Bernard Sanders,
Chairman of the Subcommittee, presiding.
Present: Senators Sanders [presiding], Casey, Murphy,
Kaine, Hassan, Rosen, Collins, Murkowski, Marshall, Scott, and
Braun.
OPENING STATEMENT OF SENATOR SANDERS
The Chairman. Let me call the hearing to order, and thank
Senators who are here, and to mention that the issue that we
are discussing today is a very sobering issue and it is an
issue I think does not get the kind of attention that it
deserves. And let me thank Ranking Member Collins for her
interest in the topic.
Let me thank Dr. Kathleen Harris, Dr. William Cooke and
Chief of Police, Chief Robert Mackenzie for joining us for this
hearing today. They are going to be with us virtually. You
know, in the U.S. Congress, we have our differences of opinion,
to say the least. But I think every member works hard on the
issues of importance to his or her state or congressional
district. But I think sometimes we may, in the midst of our
work, lose sight of the big picture, the really big picture of
what I think all of us want to accomplish.
Very simply stated, what I want, and I believe Members of
the Committee want, and certainly the American people want, is
to create a Nation in which the people in the United States can
live long, healthy, happy, and productive lives. At the end of
the day, that is what we are fighting for. Unfortunately, the
issue we are discussing today, as I mentioned, does not get
nearly enough attention, but it is surely an ongoing tragedy,
something that we need to focus a lot more, work on. And that
is that here in the wealthiest Nation, in the history of the
world, where we spend far more per capita on health care than
people in other countries, the truth is that our life
expectancy, how long our people live, trails behind many other
industrialized countries.
Tragically and the question of today, what we are
discussing is life expectancy in the United States right now,
for many, many people, is in decline. And when we discuss the
issue of life expectancy, the real outrage, it seems to me, and
this is above and beyond the culprit, the horrors of the COVID
pandemic, is that not all of our society is seeing a decline in
life expectancy. What we have seen over the last number of
years, again, pre-COVID, is that this declining life expectancy
is impacting lower income and working people in a very
significant way, people with less education, and people who
live in rural areas. In terms of life expectancy, as it
happens, the very wealthy are doing just fine. The crisis
impacts particular people, working people, lower income people,
people living in rural communities.
One of the most alarming facts, I think, that we have to
address as a Nation is that today, and I want everybody to hear
this, an upper income male lives 15 years longer than the
poorest male. And the gap between women is 10 years. According
to a report by the Health and Equality Project, from 2001 to
2014, the wealthiest Americans gained approximately 3 years in
life expectancy, while the poorest Americans experienced no
gains. A three-year difference in life expectancy may seem
trivial. What is 3 years? But as the report's authors note,
this gain in lifespan is the equivalent of curing cancer for
only the wealthy.
Imagine that wealthy get cured, everybody else does not.
Let me give you another example. If you are upper income, if
you have stable housing, if you have access to decent medical
care, you are doing fine. Today in Fairfax County, Virginia,
for example, the median household income is $124,000 and the
poverty rate is just 6 percent. A child born in Fairfax County,
Virginia, today could expect to live to 85 years of age. That
is pretty good. It is pretty good in terms of international
standards. It is good. But in Scott County, Indiana, where Dr.
Cook has his medical practice, the median household income is
$48,000 and almost 14 percent of the community lives in
poverty. A child born there today could expect to live only 71
years. Imagine that, 14 year discrepancy between Fairfax
County, Virginia and Scott County, Indiana.
In other words, what we are discussing today, and this is
such an important point, is poverty is like that. You, are the
big house, I have a small house. You are driving a fancy car. I
have a broken old car. That is not what we are talking about.
What we are talking about is that if you are wealthy in
America, you will live many, many more years than if you are
poor. So it is not a question of luxuries. It is a question of
literally poverty and stress being a death sentence. And all of
this is preventable. And I think and hope that all of us can
agree that this reality of today is a moral and economic
failing. Over the past 10 years, the disparities have grown
exponentially. And this is above and beyond the onslaught of
the COVID pandemic, which has done, all the horrible things and
the deaths that it has caused. As we will hear from Dr. Harris
today, mortality is now flat or rising among most working age
populations.
Socioeconomic disparities have widened substantially,
especially by education levels. People who obtained a
bachelor's degree are doing much, much better than those who
have not gotten that quality of education. And what makes this
even more stark is that many of these premature deaths are
preventable. This is not about needing more advancement in
medical research.
In fact, cancer death rates are declining for more than
half of the most common cancers in the U.S. We are making
significant progress than in another many years. This is not
about health care. We are seeing a nationwide crisis of what
doctors call, ``deaths of despair.'' ``Deaths of despair.''
What does that mean? It means that we are seeing an increase
and will discuss the history of drug overdoses, opioid
epidemic, alcoholism, and even suicides. A Stanford
neuroscientist, Robert Sapolsky, who has been speaking and
writing on this topic for decades, offers a simple answer as to
why we are seeing this decline in life expectancy, poverty and
economic stress is what he says. The psychological impact of
being poor, a life of poverty can mean a life of constant
stress.
This is the point that I think people don't understand. It
is not having a fancy car. It is living every single day
wondering how are you going to feed your kids? How are you
going to pay the rent? How are you going to prevent yourself
from being evicted? What toll does that have on all of us? It
is extraordinary. The poor have little control over their work
schedules, whether they have jobs, how much money they make.
They fear suddenly losing the job, being unable to pay
their electric bill. What happens if your electricity goes out?
What happens if you don't have a cell phone? They despair over
their own future and how to give their children a better life.
They are exhausted and socially isolated by second or third
jobs, long commutes, and weekend shifts. They lack the means to
take much needed time off or pay for relaxing hobbies.
Often their social support systems are decimated by
incarceration, addiction, and depression. And I can go on and
on, but I think I have kind of laid the table for what I hope
we will be discussing today. I know Senator Collins has long
been interested in these kinds of issues. We appreciate your
help.
Senator Collins.
OPENING STATEMENT OF SENATOR COLLINS
Senator Collins. Thank you very much, Mr. Chairman. This is
an extraordinarily important hearing that you are holding
today, and I appreciate your convening it. The pandemic and its
consequences have exacerbated many of the problems that were
already fueling declines in life expectancy. Just this morning,
The Wall Street Journal reported that U.S. life expectancy fell
by 1.5 years in 2020. That is the biggest decline in
generations. And the largest drop was among Hispanic men.
One of the clearest consequences of the pandemic is the
escalating incidence of behavioral health problems and
substance abuse disorders. Overdose deaths have soared by 30
percent during the pandemic. Last year, 504 Mainers died from
overdoses, a tragic record that exceeded the deaths caused by
COVID-19 in 2020. Let me say that again. More Mainers died from
drug overdoses last year than died from the tragic pandemic.
Regrettably, 2021 may be even worse as Maine has averaged
nearly 50 overdose deaths a month so far this year.
Like Americans of all ages, young adults had a tough time
coping with the pandemic, the lockdowns. And other
consequences. And they reported much higher levels of anxiety
in a CDC survey conducted last summer among young people aged
to 18 to 24. Nearly a quarter reported that they had started or
increased their abuse of substances to cope with pandemic
related stress or emotions. The survey also revealed that 25
percent seriously considered suicide. Many who have struggled
with the chronic illness of addiction long before the pandemic
found it more difficult to access the treatment they needed, to
participate in counseling, and peer to peer support during the
pandemic as young adults started to become parents themselves.
The stakes have become infinitely higher. In Maine, about 8
percent of babies born in 2018 had some degree of neonatal
abstinence syndrome. This summer alone, a three-year old from
Old Town died. An 11 month old from Correna suffered a near
fatal fentanyl overdose. In 2017, the Portland Press Herald ran
a 10 part series titled ``Lost, Heroin's Critical Killer Grip
on Maine's People.'' And one of the installations in the series
focused on women and the challenges that they face.
The article said that when it comes to opioids, women are
at a deadly disadvantage. They are dying of overdoses at
increasing rates compared with men. They get addicted faster
and feel withdrawal more acutely. They are often dealing with
sexual trauma as well as their addiction. They tend to avoid
seeking treatment if they are mothers because they fear their
children will be taken away from them. And when they do ask for
help, there are fewer resources available for them. One of the
themes that we will hear today is the importance of engaging
local communities. The structure and connection that can be
found in employment, schooling, church, and community groups
not only helps with identity and giving life a sense of
purpose, but also they can be an essential source of peer
support.
I am very pleased that with us today is Kennebunk's Police
Chief, Robert MacKenzie, and he will talk about his impressive
efforts, including working with Rotary International. Another
theme, which is near and dear to the Chairman's heart as well
as mine, is access to health care, for example. Those working
and highly physical and dangerous professions such as the
lobster fishing industry, for them, the time and travel to take
care of anything other than emergency health care needs can
deter them from seeking regular care for conditions like high
blood pressure and diabetes.
Last year, I joined a bipartisan group of Senators in
introducing legislation to expand Telemental Health Services in
rural areas, the home based Telemental Health Care Act would
establish a grant program for health providers to provide
telemedicine service for those in farming, forestry, and
fishing industries. Another focus of the National Academies of
Science report are cardio metabolic conditions. I will never
forget last year the owner of an ambulance service telling me
that his calls were way down.
It wasn't due to the fact solely that there were fewer
automobile accidents since people were not driving. It was that
people who were experiencing symptoms of heart attacks were
afraid to go to the hospital during COVID. And they should
have. We also saw people putting off treatment and screenings
that might have uncovered cancer at an earlier age. Here again,
community interventions such as those where people can
participate virtually like diabetes self-management training
can help change the trajectory of life expectancy.
As we continue to grapple with the delta variant and emerge
from the pandemic, we should take stock in the areas where we
have done well, like telehealth, as well as to analyze those
areas that have worsen, like substance abuse disorders. So this
hearing is very well timed, and I look forward to hearing from
our panel. Thank you, Mr. Chairman.
The Chairman. Well, thank you very much, Senator Collins.
Senator Casey has to run so I am going to ask him if he would
like to speak for a few minutes.
Senator Casey. Mr. Chairman, thanks very much. I want to
thank you and the Ranking Member for convening this hearing,
and I will be brief. I start with an apology that I won't be
able to stay for the entirety of the hearing. I will make sure
that I and my staff review the testimony, the written testimony
of Dr. Harris, Dr. Cooke, and Chief MacKenzie, and then submit
questions for the record. But I want to thank you, Mr. Chairman
and the Ranking Member for having this hearing. The documented
decline in life expectancy for working age adults in our Nation
and the socioeconomic disparities that are part of that trend
are alarming, disturbing, and I think all of us--need to do
something.
Mr. Chairman, you were talking about in your opening
remarks, the impact of stress and poverty on people having not
just an adverse health impact, but literally being for some
people, many people, a death sentence. That caught all of our
attention, and the deaths of despair that you made reference to
should call all of us to action. I know in Pennsylvania, we
have a huge--still a huge challenge with substance use
disorder.
I have to say the Medicaid expansion in our state helped a
lot, but the pandemic wiped out a lot of those gains. More than
16 percent--the number of overdose deaths in our state
increased, I should say, by 16 percent from 2019-2020, and that
doesn't, of course, cover the whole impact of the pandemic. So
I am grateful for this indulgence. I am grateful for this
hearing. Thank you.
The Chairman. Thank you very much, Senator Casey. And now
we will get to our panelists who are with us virtually from
around the country. And let me begin by introducing Dr.
Kathleen Harris, who is a Professor of Sociology, Adjunct
Professor of Public Policy and faculty fellow at the Carolina
Population Center at the University of North Carolina.
Dr. Harris's research focuses on social inequality and
health, and she is the Chair of the Committee on Population at
the National Academies of Sciences, Engineering and Medicine.
Dr. Harris, thank you very much for being with us today.
STATEMENT OF KATHLEEN MULLAN HARRIS, PH.D., JAMES E. HAAR
DISTINGUISHED PROFESSOR OF SOCIOLOGY, UNIVERSITY OF NORTH
CAROLINA, CHAIR, COMMITTEE ON RISING MIDLIFE MORTALITY RATES
AND SOCIOECONOMIC DISPARITIES, THE NATIONAL ACADEMIES OF
SCIENCES, ENGINEERING, AND MEDICINE, CHAPEL HILL, NC
Ms. Harris. Good morning. Chairman Sanders, Ranking Member
Collins and Members of the Subcommittee, thank you for the
opportunity to testify today. My name is Kathleen Mullan
Harris. I am the James Haar Distinguished Professor of
Sociology at the University of North Carolina, Chapel Hill. And
I am speaking to you today in my capacity as Chair of the
National Academies Committee that produced the study, high and
rising mortality rates among working age adults. As you just
heard, our study was motivated by a huge problem.
Between 2014 and 2017, life expectancy in the United States
fell 3 years in a row, the longest sustained decline in a
century. To make matters worse, this was not happening in our
high income peer countries. So we wanted to understand why more
Americans were dying in the prime of their lives, ages 25 to
64, the most productive years and their parenting years. So we
first set out to identify what causes of death were increasing
and for whom. We examined trends from 1990 to 2017 and
identified three main drivers of rising mortality, deaths due
to drug poisoning and alcohol induced causes, suicide, and
cardiometabolic diseases like hypertension, diabetes, stroke,
and heart disease.
Rising death rates first occurred among younger white women
and men, those aged 25 to 44, living outside of large cities,
but then spread to most racial and ethnic groups and geographic
areas of the country. Although rising death rates began among
whites, Blacks consistently experienced much higher mortality.
Those with less education and income always experienced higher
death rates, and this disadvantage was widening among whites.
Geographic disparities also widen between large urban areas and
less populated rural areas, where death rates were increasing
more rapidly, especially in Appalachia, New England, the
industrial Midwest, and parts of the Southwest and Mountain
West.
What was happening? We then searched for explanations
through an extensive review of the existing research
literature. Drug and alcohol related deaths were the most
important contributor. Explanations involve supply side factors
like weak Government, Governmental oversight, and actions by
the pharmaceutical industry, pain control advocacy groups, and
physician prescribing. Demand-side factors included increasing
prevalence of physical pain, declining psychological health,
and long term trends of economic adversity that affected adults
with less than a college education and geographic areas where
manufacturing and mining jobs had disappeared.
Suicide rates increased primarily among whites, especially
white men, and in less populated rural areas. Economic factors
are important. Economic downturns, low wages, increasing
foreclosure rates and a weak safety net increase suicide rates.
Cardiometabolic diseases also played a significant role, a
complex role. Up until 2010, science was saving us. Medical
interventions and public health campaigns to reduce smoking
drastically cut down cardiovascular death rates. But these
declines hit the mountain tsunami of the obesity epidemic,
which was fueling alarming increases in hypertension, diabetes,
stroke, and heart disease.
By 2010, the lagged effects of obesity overwhelmed what
medicine could do to save lives. So you can see there is no one
cause that explains the increase in death rates, but we noted
three common factors underlying all the trends economic
adversity, two, economic inequality, and volatility. Every one
of these trends and the themes underlying them are being
magnified by the COVID 19 pandemic. This is a crisis in America
that existed before COVID, and it will continue after COVID.
Our life expectancy is declining relative to our peers
despite our wealth. Solutions need to be multifaceted. The
committee made several recommendations. We need policies that
can be implemented for those agencies and stakeholders closest
to the addiction crisis to improve regulation and oversight and
modify practices just for the prevention and the treatment of
substance use disorders. Economic policies are needed to
address the economic and social strains that make communities
vulnerable to opioids and other drugs. Obesity prevention
programs need to start early in life before obesity and focus
on the most vulnerable, often the low income populations.
We need to balance the right of the food industry and
public health imperatives to reduce food and beverages that
contribute to obesity. Death rates are lower in states that
have expanded Medicaid under the Affordable Care Act. The 12
states that have not yet expanded access to Medicaid should do
so as soon as possible.
All studies of mortality report on the stark disadvantage
and life expectancy among racial and ethnic minorities in the
United States. Reducing this racial gap will significantly help
to improve our global standing in life expectancy and catch up
to our other rich nations.
Thank you for the invitation to testify and I welcome any
questions you have.
[The prepared statement of Ms. Harris follows:]
prepared statement of kathleen mullan harris
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Dr. Harris, thank you very, very much. I
believe that Senator Braun is going to introduce Dr. Cooke.
Senator.
Senator Braun. Thank you, Mr. Chairman and Ranking Member
Collins. My pleasure to introduce Dr. William Cooke, fellow
Hoosier. Graduated with honors from the IU School of Medicine
in 2001. Completed his family medicine residency at Memorial
Hospital in Muncie, Indiana. Dr. Cooke is a fellow of the
American Academy of Family Medicine and the American Society of
Addiction Medicine, specializing in addiction and HIV medicine.
He has received national recognition for quality and
compassionate care, including being named Family Physician of
the Year by the American Academy of Family Physicians.
Dr. Cooke lives in his hometown of New Albany with his wife
Melissa and their six kids. He also serves as the Executive
Director of a nonprofit Refresh, the hospital's Medical
Director at the Critical Access Hospital in Scott County, and
Co-Director of the Rural Center of HIV and STD Prevention. In
2015, Austin, Indiana became the epicenter of the national
opioid crisis and the worst drug fueled HIV outbreak in U.S.
history. At the time, Dr. Cooke was the only physician in this
rural Southern Indiana town.
In response, he and his team went the extra mile to improve
their own capacity to care for people living with HIV, even
going door to door in his community to provide care for the
people newly diagnosed. Today, almost 80 percent of Dr. Cooke's
patients living with HIV have undetectable viral loads. Dr.
Cooke continues to provide full spectrum primary care to those
in his community, including the people with substance abuse
disorders and mental health challenges. Look forward to hearing
your testimony today.
The Chairman. Dr. Cooke.
STATEMENT OF WILLIAM E. COOKE, M.D., FAAFP, FASAM, AAHIVS,
OWNER AND MEDICAL DIRECTOR, FOUNDATIONS FAMILY MEDICINE,
AUSTIN, IN
Dr. Cooke. [continuing]. Just a few seconds to thank
Senator Braun and the other panelists, Sheriff MacKenzie and
Dr. Harris presenting today. Good morning, Chairman Sanders,
Ranking Member Collins and other Members of the Subcommittee. I
spent the last two decades working to increase health equity in
underserved areas of Southern Indiana. That is where I grew up,
surrounded by poverty, toxic stress, and substance use. And
those factors actually contributed to my grandpa's death in his
50's, my aunt's overdose death at the age of 39. Although my
parents escaped that fate, providing my brother and me greater
opportunity, our family remains an example of how early death
profoundly affects life expectancy.
During medical school, I was impressed by our Nation's
investment in research and technology. There is no place on
earth better keeping sick people alive. After graduating as a
family physician, I felt prepared to care for the entire
community at my health clinic, regardless of the age or
condition, at our critical access hospital, delivered babies,
worked in the emergency department, and treated critically ill
patients. Even so, nothing could have prepared me for the
suffering I found in the Nation's heartland.
Young people with late stage diabetic complications, women
dying of cervical cancer, and a man with a tumor on his tongue
so large he couldn't even close his mouth. These encounters
made me realize that we focus so heavily on treating sick
people that we forgot to promote healthy people. As the Surgeon
General's report on community health and economic prosperity
indicates, our Nation is at a health disadvantage due to
inequitable access to vital community conditions that shape
health and well-being, such as clean air and water, nutritious
food, safe housing, reliable transportation, a livable wage,
and a sense of belonging and civic power. There are far too
many people like my patients who lack these vital conditions.
Children don't choose where they are born or where they are
raised, and if they were born into these low opportunity
neighborhoods, their life chances are diminished all the same.
Life was more comfortable before I recognized these inequities.
My discomfort caused me to cling to beliefs that I had been
taught about people who were different than me. But close
encounters with real people convinced me that health and
prosperity are not solely dependent on comfort or choice but
are often limited by access to resources and opportunity. After
all, people could only make choices from the options available
to them.
The greater the inequality, the greater the inequity, the
greater the burden of disease, disability, and early death. We
must move beyond the path of disease oriented model and do no
harm, to a proactive person centered model of protect from
harm. And primary care physicians are uniquely positioned to do
just that. Research confirms access to primary care improves
health outcomes and life expectancy. Now, you have heard a lot
of bad news from the report. Let me just share some hopeful
progress we have made in Indiana. As Senator Braun mentioned,
my community experienced the worst drug fueled HIV outbreak in
U.S. history in 2015. But things look a lot different today,
despite having the highest percentage of people who inject
drugs living with HIV in the state.
We have defied conventional wisdom by being able to boast
the best viral suppression rate in the state. We went from
nearly 200 new cases a year to only 1 last year. And although
Indiana leads the country in hepatitis C cases, we have cut our
community cases by over 75 percent. We have also seen an
explosion of people with substance use disorders entering into
treatment and recovery, along with fewer diabetic
complications, better pain management without the use of
opioids, improved prenatal care, fewer hospitalizations, and
the list could go on.
We did this with very limited resources, and I believe we
have reduced the impact of social determinants on our community
by getting outside the four walls of my clinic and getting into
where people live and experience harms. A few examples include
school, jail, and mobile clinics working with the sheriff and
the recovery community to respond to overdoses and people in
crisis by providing them direct access to treatment. Project
Echo enables my team to provide interdisciplinary access to
endocrinology, rheumatology, infectious disease, addiction
medicine, and women's health.
Telehealth allows patients greater access to us and to
their support networks. And interdisciplinary teams with
diverse lived experiences help my patients feel safe accessing
care and overcoming barriers. Integrating health care with
Centerstone, a nonprofit behavioral health system, allows for
decreased stigma and barriers to mental health. Community
recovery and faith based partners help meet basic human needs
for food, safety, and belonging.
Now our fee for service system doesn't reimburse for these
interventions, which highlights the need to move toward a
payment model designed to address health inequities. Health
care disasters don't just happen, they develop right before our
eyes, unseen or ignored before it is too late, then the people
who are already suffering are the ones who are harmed the most.
We must recognize the cumulative effect of every person's
health on our Nation's health.
By taking this crisis of health inequity and declining life
expectancy on now, we can reestablish the United States as the
healthiest place in the world to live. Thank you for the
opportunity to discuss this important topic with the Committee,
and I look forward to your questions.
[The prepared statement of Dr. Cooke follows:]
prepared statement of william e. cooke
Good morning, Chairman Sanders, Ranking Member Collins, and Members
of the Subcommittee: I am Dr. William Cooke, a family physician from
Indiana. Thank you for the opportunity to speak to you today.
I've spent two decades working to increase health equity in
underserved areas of Southern Indiana. That's where I grew up
surrounded by poverty, toxic stress, and substance use. Those factors
contributed to my grandpa's death in his fifties and my aunt's overdose
death at 39. Although my parents escaped that fate, providing my
brother and me greater opportunity, our family remains an example of
how early deaths profoundly affects life expectancy.
During medical school I was impressed by the investment we've made
in research and technology. There's no place on earth better at keeping
sick people alive.
As a family physician I felt prepared to care for the entire
community at my office, regardless of age or condition. At our critical
access hospital, I delivered babies, worked in the Emergency
Department, and treated critically ill patients.
Even so, nothing could have prepared me for the suffering I found
in the Nation's heartland. Young people with late-stage diabetic
complications, women dying from cervical cancer, and a man with a tumor
on his tongue so large he couldn't close his mouth. These encounters
made me realize that our healthcare system focuses so heavily on
treating sick people it fails to promote healthy people. As the Surgeon
General's report on Community Health and Economic Prosperity indicates,
our Nation is at a health disadvantage due to inequitable access to
vital community conditions that shape health and well-being, such as:
clean air and water, nutritious food, having safe housing, reliable
transportation, a livable wage, and a sense of belonging and civic
power. \1\
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\1\ Community Health and Economic Prosperity: Engaging Businesses
as Stewards and Stakeholders--A Report of the Surgeon General,
(Atlanta: US Department of Health and Human Services, Centers for
Disease Control and Prevention, and Prevention Office of the Associate
Director for Policy and Strategy, January 2021), 11, https://
www.hhs.gov/sites/default/files/chep-sgr-full-report.pdf.
There are far too many people, like many of my patients, who lack
these vital conditions. Children don't choose to be born and raised in
these ``low opportunity neighborhoods,'' yet their life chances are
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diminished all the same.
Life was more comfortable before I recognized these inequities. My
discomfort caused me to cling to beliefs I'd been taught about people
who were different from me. But close encounters with real people have
taught me that health and prosperity are not solely dependent on effort
and choice but are often limited by the resources and opportunities
available where they live. After all, people can only make choices from
the options available to them.
The greater the inequity the greater the burden of disease,
disability, and early death. We must move beyond the passive, disease-
oriented model of ``do no harm'' to a proactive, person-centered model
of ``protect from harm.'' Primary care physicians are uniquely
positioned to do just that. Research confirms access to primary care
improves health outcomes \2\ and life expectancy. \3\
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\2\ Starfield B, Shi L, Macinko J. Contribution of primary care to
health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/
j.1468-0009.2005.00409.x.
\3\ Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE,
Phillips RS. Association of Primary Care Physician Supply With
Population Mortality in the United States, 2005-2015. JAMA Intern Med.
2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624.
You've heard a lot of bad news. I'd like to highlight some hopeful
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progress we've made in Indiana.
My community experienced the worst drug fueled HIV outbreak in U.S.
history in 2015, but things look different today. Despite having the
highest percentage of people who inject drugs living with HIV in the
state, we have defied conventional wisdom by boasting the best viral
suppression rate in the state. We went from nearly 200 new cases of HIV
in 2015 to only having one last year. Although Indiana leads the
country in hepatitis C cases, we've decreased our cases by over 75
percent. We've also seen an explosion of people with substance use
disorder enter treatment and recovery, along with fewer diabetic
complications, better pain management without the use of opioids,
improved prenatal care, reduced hospital admissions, and the list goes
on. We did this with no specialists and limited resources. I believe
we've reduced the impact of social determinants on our community by
getting outside of the four walls of my clinic. A few examples include:
Mobile, school, and jail based clinics.
Working with our sheriff and recovery community to
respond to overdoses and people in crisis by providing them
direct access to treatment.
Project ECHO enables my team to provide
interdisciplinary access to endocrinology, rheumatology,
infectious disease, addiction medicine, and women's health.
Telehealth allows patients greater access to us and
their support networks.
Interdisciplinary teams with diverse lived
experiences help patients feel safe accessing care and
overcoming barriers.
Integrating care with Centerstone, a nonprofit
behavioral health system.
Community, recovery, and faith-based partners help
meet basic human needs for food, safety, and belonging.
Our fee for service system doesn't reimburse for these
interventions, which highlights the need to move toward payment models
designed to address health inequities.
Healthcare disasters don't just happen; they develop right before
our eyes, unseen or ignored until it is too late. \4\ Then, the people
who were already suffering are the ones who are harmed most. We must
recognize that there is a cumulative effect of every person's health on
our Nation's health. But by taking on this crisis of health inequities
and declining life expectancy now, we can reestablish the United States
as the healthiest place in the world to live.
---------------------------------------------------------------------------
\4\ Cooke, W. 2021.Canary in the Coal Mine: A Forgotten Rural
Community, a Hidden Epidemic, and a Lone Doctor Battle for the Life,
Health, and Soul of the People. Tyndale House Publishers.
Thank you for the opportunity to discuss this important topic with
the Committee and I look forward to your questions.
______
The Chairman. Well, Dr. Cooke, thank you for testifying and
congratulations on your work.
Senator Collins is going to introduce Police Chief
Mackenzie.
Senator Collins. Thank you very much, Mr. Chairman. I am
delighted to introduce Kennebunk Police Chief Robert Mackenzie.
He is 33rd--a 33 year veteran of law enforcement. The Chief
recently received the Outstanding Contribution to Law
Enforcement Award from the main Chiefs of Police Association
for his incredible work in the field of substance abuse
disorder in 2020.
This was certainly a well-deserved honor and recognition
from his peers. Chief Mackenzie is a graduate of the FBI
National Academy in Quantico, Virginia, and he holds a Bachelor
of Science degree in criminal justice from Husson University.
He is a true leader in this area and I am delighted he is
joining us today. Thank you.
The Chairman. Chief.
STATEMENT OF ROBERT F. MACKENZIE, CHIEF OF POLICE, KENNEBUNK
POLICE DEPARTMENT, KENNEBUNK, ME
Mr. MacKenzie. Thank you, Chairman Sanders and Ranking
Member Collins, and Members of the HELP Committee. So I am Bob
Mackenzie, a Police Chief for 13 years in the town of
Kennebunk. But I have been in law enforcement for over 33 years
and actually in public safety since I was 14 years of age, as a
firefighter and then as an EMT from 16 years of age.
I am also a Rotarian, past President of Kennebunk Rotary
Club. I also Chair the Rotary District 7780 Recovery
Initiative. I also serve on the Board of Directors from
Milestone Recovery in Portland, Maine and United Way of
Southern Maine. So I witnessed far too many times the tragedies
due to the opioid epidemic and disease of substance use
disorder, otherwise known as SUD. Now as devastating as these
losses are, it became even more real for me when I realized my
daughter was suffering from an opioid use disorder. Now,
because of my work on an SUD that specialized in the opioid
epidemic, I knew my daughter was at great risk for death.
I was fortunate to have the resources and know how in order
to help my daughter find her path to sobriety, and I am proud
to say she is more than 18 months in recovery now. I also know
that there are many loved ones not as fortunate as mine and
2020 certainly proved to be a devastating year, and not only
because of COVID, but because of the loss of lives to SUD and
the opioid epidemic. The most recent national statistics I have
seen for 2020, as Senator Collins said, was a 30 percent
increase over 2019, but that equates to about 93,000 Americans
that died. And what is important to remember is that these
stats are somebody's loved ones. Now, on a positive note,
resources for SUD have and will continue to adjust for the
pandemic and we are becoming very creative as to our approach.
We have implemented a number of initiatives in our region
over the past 5 years and I will share three of them that I
believe are most relevant for this discussion. The first thing
we needed to do is reduce stigma, because stigma is the No. 1
barrier for those that suffer from SUD to enter recovery.
Stigma related to SUD is far too prevalent in our society. But
once people are educated, they tend to open their minds and
their hearts.
I began educating our Kennebunk Rotarians on SUD and the
opioid epidemic and trained them on how to use naloxone, which
is the drug that reverses an opioid epidemic--overdose, that
is. I went on to train our Chamber of Commerce, our businesses,
held several community forums, and even students at Kennebunk
High School. I have trained at least 35 Rotary Clubs throughout
Maine and New Hampshire, all with the goal of raising awareness
and reducing stigma. Now, another initiative that is currently
underway in our community is called Kennebunk Area Response to
Substance Use Disorder.
This is where we convene stakeholders of three towns to
include our town managers, law enforcement positions, recovery
centers, faith based leaders, mental health providers, those in
recovery and more. We first identify the issues surrounding
SUD, what resources we currently have, but even more important,
we identify gaps so we can create a strategic plan to close
those gaps. This type of initiative educates everyone and so we
are all on the same page, we are more efficient, cost
effective, and we are not working in silos any longer.
The third initiative in the Kennebunk area includes a
community based fundraising group called Above Board that came
forward with a desire to raise money to support our efforts on
saving lives. A total of $110,000 was raised and was utilized
to train community members to become recovery coaches. A
recovery coach is a mentor to those with SUD and helps them
find a path to recovery and stay in recovery. In addition,
these funds were used to train our law enforcement officers on
how to help those with SUD.
Now there are times when law enforcement needs to use
enforcement, but there are many more times when law enforcement
officers can be an ally and help those in need. I am proud to
say that this model of law enforcement training became a
mandatory training module for all of our officers in the State
of Maine last year. These are only a few of the initiatives we
have undertaken in our region. Our community is dedicated to
helping those with SUD because we know recovery is possible. I
have seen it through my own family, and even more so at work
with those struggling with SUD were at great risk of death, but
are now healthy, happy, and productive citizens who are doing
great work to strengthen the recovery community.
The key word here is community. It is by working together
at the local level where we know our community is the best and
have the ability to utilize the resources of the state and
Federal Governments, we will make a difference and save lives.
I thank you for your time and attention to this matter and
welcome any questions that you may have.
[The prepared statement of Mr. MacKenzie follows:]
prepared statement of robert f. mackenzie
Thank you Chairman Sanders, Ranking Member Collins and Members of
the H.E.L.P. Committee. My name is Bob MacKenzie and I am the Chief of
Police in Kennebunk, Maine. I am a veteran of public safety for over 40
years, to include 33 years in law enforcement, serving as Chief for the
past 13 years, and also served as a firefighter/Emergency Medical
Technician up to the Critical Care level for over 30 years. I am also a
proud Rotarian, Past-President of the Kennebunk Rotary Club and
Chairman of the Rotary District 7780 Recovery Initiative. I also serve
on the Board of Directors for Milestone Recovery and am a board member
of United Way of Southern Maine.
I appreciate the opportunity and am honored to testify before you
on a subject near and dear to my heart, the Opioid Epidemic and
Substance Use Disorder and how it has impacted our society through not
only the lens of a devoted public servant, but as a father.
Through my decades of public safety, I have been a firsthand
witness to the death and destruction caused by the disease of substance
use disorder, (SUD) and the Opioid Epidemic far too many times. I have
seen families devasted by the loss of their sons/daughters, bothers/
sisters, mothers/fathers, and so on.
As devastating as these losses are it became even more real for me
when I realized my daughter was suffering from an opioid use disorder.
Because of the work I have been doing on SUD, specializing in the
opioid epidemic, I knew my daughter was at great risk for death and I
was afraid I would be on the receiving end of a death notification. I
was fortunate to have the resources and know-how in order to help my
daughter find sobriety. It wasn't easy for her as she experienced a
reoccurrence, but I am proud to say she is now 18 months in recovery
and working with me on an initiative to help others with SUD.
There are many families and loved ones not as fortunate as ours and
2020 was a devastating year, not only because of COVID, but because of
the loss of lives to SUD and the Opioid Epidemic. Maine saw a 33
percent increase in overdose deaths in 2020, losing 504 lives to
overdose. The most recent national statistics I have seen shows a
similar 30 percent increase, estimated to have a death toll of 93,000
Americans compared to over 72,000 deaths in 2019. What's important to
remember, is these statistics are somebody's son/daughter, brother/
sister, mother/father, etc. . . . My heart goes out to each and every
one of them.
There have been resources allocated to SUD and the opioid epidemic,
so you may ask why are we failing? We had made progress pre-pandemic,
but SUD is a disease of isolation. COVID forced all of us to isolate
and many of the resources that had been made available for those
suffering with SUD were no longer available or took much time to adjust
and could only be utilized remotely. Many of those with SUD do not have
the resources to utilize online services. It is typical for those that
use to use in solitude, and many die alone after using opioids.
On a positive note, resources for SUD have and will continue to
adjust for the pandemic and we are becoming creative as to our
approach. We have implemented a number of initiatives in our region
over the past 5 years.
An example I will use is what we have done in Kennebunk, ME. The
first thing I knew we needed to do was reduce stigma as stigma is the
#1 barrier to recovery for those that use. Stigma related to SUD is far
too prevalent in our society. Many believe those that use substances
are less than and have little value in society. Once educated, people
tend to open their minds and their hearts, thus progress can be made.
I first educated Kennebunk Rotarians on SUD and the opioid epidemic
and trained many how to use Naloxone, the drug that reverses an opioid
overdose. Once that was completed I trained our Chamber of Commerce,
businesses, community members through various forums, Adult ED and even
students at Kennebunk High school. Then our Rotary District became
involved and I trained at least 35 Rotary clubs, presented at our
Rotary District conference where I was fortunate enough to educate over
100 Rotarians from three Rotary Districts, and have traveled throughout
Maine, New Hampshire Connecticut and upstate New York. Rotary Clubs in
seacoast New Hampshire have held community forums on SUD and the Opioid
Epidemic. All with the goals of reducing stigma and saving lives.
A new initiative our Rotary District has embraced and is
financially supporting is the training of 30 Master Trainers with the
goal of educating communities throughout our region on Adverse
Childhood Experience's, otherwise known as, (ACE's). ACE's has proven
to have significant negative outcomes on physical, mental and
behavioral health, to include SUD for individuals and communities.
These master trainers are now training school officials, law
enforcement, community members and more to identify and work with at
risk youth in a trauma-informed way. Approaching problems in a
constructive, understanding way, called trauma informed care, rather
than traditional punitive methods, has a substantial positive impact on
future levels of addition, crime, violence and other societal issues.
A third initiative in the Kennebunk area includes a community-
based, fund-raising group called Above Board that came forward with the
desire to raise money to support our efforts on savings lives in 2018 &
2019. A total of $110,000.00 was raised and was used to train community
members to become Recovery Coaches. A Recovery Coach is a mentor to
those with SUD and helps them find their path to recovery, and stay in
recovery. In addition, these funds were used to train our law
enforcement officers on how to help those with SUD. There are times
when law enforcement needs to use enforcement, but there are many more
times when law enforcement officers can be an ally and help those in
need. I am proud to say that this model of law enforcement training
became a mandatory training module for all officers in Maine last year.
We also were able to utilize these funds to partner with a mental
health agency as so a clinician would ride-along with officers and
assist those with SUD and mental health issues.
The fourth initiative currently underway in our community is the
Kennebunk Area Response to SUD. We convened stakeholders of three towns
to include, town managers, law enforcement, physicians, recovery
centers, faith based leaders, mental health providers, those in
recovery and more. We first identified the issues surrounding SUD, what
resources we currently have but even more important, identified gaps as
so we can create a strategic plan to close the gaps. This type of
initiative educates everyone as so we are on the same page, are more
efficient, cost effective and not working in silos.
The fifth initiative we have utilized in Kennebunk are interns. In
early 2020 we partnered with the University of New England to bring on
an intern from UNE's School of Social Work where we had a graduate
student intern at Kennebunk PD for a full semester. This student was
supervised by a licensed clinician, but was able to conduct ride-along
with officers as well as conduct follow-ups on those who were
struggling with SUD and mental health issues. Given the success of this
initiative, we are currently in a process to hire a mental health
clinician. We also utilized AmeriCorps to have a VISTA intern at our PD
for 2 years to provide additional support for our efforts on SUD.
A sixth initiative prior to the pandemic was partnering with The
Family Restored, which is a support group for families of loved ones
struggling with SUD. Family is a support network and can play a
critical role of a loved ones recovery. I had many sleepless nights
when my daughter was struggling, and I had a pretty decent handle on
resources and what needed to be done. Most families are at a loss,
don't know what to do or where to turn and in many instances
unknowingly enable their loved ones. Family support groups is a harm
reduction tool and should be prevalent and accessible throughout our
country.
Even with the initiatives we have brought forth there are many
other initiatives which would be very beneficial and I feel are needed
in order to have the best outcomes and save lives. Here are some of my
thoughts:
Peer led recovery community centers, such as the Portland Recovery
Community Center, (PRCC) is a community center open to those in need.
PRCC's vision statement explains it well:
PRCC's vision is that every person affected by addiction in
Maine will have direct access to a local recovery community
center that provides support groups, education, and individual
resources to enhance their ability to heal, strengthen and grow
in their recovery pathway, throughout all stages of their
journey.
Maine currently has 13 recovery community centers with the goal of
17, one for each county in Maine. I believe once again we need one in
every community in our Nation as SUD is that prevalent.
Another vital need is recovery/detox centers. I can speak as a
board member of Milestone Recovery in Portland, Maine which is a non-
profit center providing a life-saving function to those with SUD from
all over. Milestone runs on a very tight budget but does not refuse
anyone who cannot pay. In Maine there are very few options for recovery
centers, and many of the ones we do have are for-profit. Many with SUD
do not have the means to pay or have health insurance that cover the
costs, so there are many times where people in need do not receive the
help they want/need. It is important to note that many of those with
SUD who are ready for recovery only have a short window to get help
before their disease changes their mind.
It is my opinion that mental health clinicians should be available
to every law enforcement agency. Based on our experience with our
intern and clinician, and based upon my over 33 years on the job, we
need the expertise of a licensed professional clinician to assist us,
not only at the time of mental health events, but to conduct follow-up
with those suffering from SUD/mental health calls that law enforcement
come into contact with. Clinicians have the know-how, time and ability
to connect those in need to the correct services. Although law
enforcement officers are not licensed mental health clinicians, we
routinely have to play that role as options are limited to those in
need. Our agency and town has benefited from the COPS hiring grants in
the past, but now is the time to allocate funds for licensed clinicians
to be embedded within law enforcement agencies. It's not only a
community policing initiative, it will save lives and save money in the
long run.
Thank you once again for this opportunity and I appreciate your
time to this critical issue facing our country. By working together we
will make a difference and save lives!
______
The Chairman. Chief, thank you very much. Let me begin the
questioning with Dr. Harris. Dr. Harris not only are we seeing
a decline in life expectancy in many parts, many sectors of our
society, but we have for many years lagged behind other
wealthy, industrialized countries.
What impact would it have on life expectancy in America if
all of our workers had decent wages, that was at least a
livable wage, decent housing, and if we did what every other
major country on earth does and provide health care as a human
right? Would that, in your judgment, impact life expectancy in
the country?
Ms. Harris. Yes, it would. A lot of people look at the
differences in life expectancy between the United States and
our peer countries and, attributed it to the racial and ethnic
disparity. But even if we eliminated that, we would still be
behind. So the cause is much deeper and broader, and it is
rooted in inequality, socioeconomic inequality, poor economic
conditions, and the stress of living with those conditions.
I think that opportunities for jobs, if everybody had a job
that would provide them with a sense of meaning and dignity and
purpose in life, and it would allow them to take care of their
families or promote their children or upward mobility. And I
think that would really cut to the heart of helping us catch up
to other rich nations in life expectancy.
The Chairman. Thank you very much. Let me ask Dr. Cooke a
question, and congratulations, Doctor, for the work that you
are doing taking health care out of the clinic, into the
community. Talk a little bit about, if you might, the
physiology of poverty. What happens to somebody who is
struggling economically, who maybe has given up hope for
himself or herself, the kids? How does that impact their
outlook on life and their tendency to use drugs, alcohol,
suicide, self-destructive behavior?
Dr. Cooke. Yes. Oftentimes when I am working with people, I
realize that they have made a lot of effort in their life to
get to where they wanted to be in life. But somewhere along the
way, circumstances had appeared to be so overwhelming that they
developed this sense of learned helplessness. No matter what
they do, they can't get ahead. And one of the things that I
found is the most helpful when I am working with people is
trying to reestablish within them the sense of purpose and
meaning.
When they find that and they are able to project that into
the world, all of a sudden some of those circumstances don't
seem as overwhelming any longer. And when we look at substance
use disorder, the recovery community is such a vital piece of
that. But toxic stress is damaging to the body. It is damaging
to the mind, the brain the way it is developed with childhood--
adverse childhood experiences. It disrupts the neural
development, and it leads to these behaviors that then lead to
poor health outcomes, unfortunately.
The Chairman. Thank you. Chief MacKenzie, as a Police
Chief, you and your department are on the front lines every day
dealing with these things, in your personal judgment, what are
the causes today that bring young people especially to a
dependency on drugs or alcohol? What is going on?
Mr. MacKenzie. Certainly. Well, I agree with regard to the
issue around adverse childhood experiences. A lot of research
has been--the scientific research has been done on that. So
children that grow up with adverse experiences in their home
are much more likely to have issues anywhere from suicide
health issues, but also substance use disorder.
Any child that grows up in that type of environment, they
could be subject to substance abuse in their home, separation
or divorce of their parents, mental illness, domestic violence,
neglect, both emotional, physical, or sexual abuse. But the
more issues that they have, the more chances are that their
life expectancy is going to be shorter.
I know there was a Florida study of juvenile offenders who
have 50 percent of them had an ACE score of four or more. And
to put that in perspective, those with ACE scores of 4 or more
were 12 times more likely to have attempted suicide, 7 times
more likely to be an alcoholic, or 10 times more likely to have
injected street drugs, and ACE scores of 6 or higher, an almost
20 years short end of lifespan. So I definitely feel that ACE
has a lot to do with it.
The Chairman. Well, thank you very much, Chief.
Senator Collins.
Senator Collins. Thank you, Mr. Chairman. Let me begin my
questions by first thanking Chief Mackenzie and Dr. Cooke for
so eloquently sharing with the Committee your own family's
struggles. It certainly puts a human face on the statistics,
and it reminds each and every one of us, if we don't already
know it, that no family is immune. And I think that is a really
important lesson.
Thank you for your willingness to share your own personal
stories. Chief, I want to start with you. Prior to the start of
the COVID pandemic, we started to see some glimmers of progress
in the State of Maine. I remember in 2018 and 2019, the number
of deaths, while still unacceptably high, was going in the
right direction. It was declining.
Then Congress had passed a lot of legislation to help,
including a bill that I co-authored related to opioid peer to
peer support networks and safe disposal of unused medications,
and Congress also significantly ramped up the funding that we
provided. And yet once the pandemic hit, we seemed to lose all
of the progress that we made.
Indeed, as both you and I mentioned, Maine experienced a
record number of losses, 504 deaths last year, which was a 33
percent increase over the year before. What happened? What
factors do you think caused us to lose the ground that we were
gaining?
Mr. MacKenzie. Certainly. So, once COVID came--once COVID
came, what we were told to do is isolate. Now, substance use
disorder is a disease of isolation. Many people that use, use
in solitude, they are by themselves when they use in many
instances. Now, in addition, many, many of the resources that
have become available were really no longer available,
especially the peer to peer support, the in meeting--the in-
person meetings that were being held.
Now we tried to struggle through that and be creative and
maybe do some meetings via zoom and other platforms. But one of
the issues is that many people that utilize substances do not
have the resources or the ability to go online. It is not just
that easy for them. So COVID certainly just forced the issue of
isolation more. And I believe that is why we have seen such an
issue with the deaths increasing.
Senator Collins. Thank you. Dr. Cooke, in the Chief's
testimony he referred to the stigma of getting assistance. I
believe it was the Chief that mentioned that. And I have seen
that time and time again in talking with friends who are
struggling or have children who are struggling. I have also
seen a success story in this regard, and that is at the V.A..
The Veterans Administration has been using telemedicine to
reach out to veterans in rural areas who are struggling with
substance abuse disorders or other behavioral health
challenges.
What they have found is their no-show rate has dropped
dramatically and that the veterans got much more comfortable
with telemedicine counseling and treatment sessions than they
did being seen going into a counselor's office. Now, that said,
that there is that stigma. But I wanted you to comment, you
alluded to the fact that we need to revise our reimbursement
policies because we temporarily are reversing--or reimbursing
while COVID is going on, but I fear that is going to come to an
end. How important is telemedicine in reaching people and how
important is that reimbursement?
Dr. Cooke. Thank you for that question. We told everybody
to socially isolate, right, socially distance from each other,
and I think what we meant by that was physically distant from
other people. We really needed to maintain our social
connections with other people. And telemedicine is a wonderful
tool to be able to do that. It doesn't replace in-person
meetings. It doesn't replace face to face interactions with
people, but it does allow us to stay connected to people that
we would otherwise be physically distant from.
By--if you look at the Ryan White program, there is a
reason why the viral suppression rate of people living with HIV
in the Ryan White program is better than in other clinics. And
that is because they address those underlying critical, vital
community conditions, those social determinants of health, that
social health and equity of transportation and such. By
allowing those Ryan White funded clinics access to money that
can provide transportation, that can provide social
interactions, and support groups.
We just recently developed a statewide support group for
people living with HIV so they know they are not alone, and we
can get through this together. So I think looking at a unique
ways to reimburse, better ways to stay connected with people to
support them having those access to vital community conditions,
would help support healthy people and not just continue to
focus on the disease model.
Senator Collins. Thank you.
The Chairman. Thank you, Senator Collins.
Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman. Thank
you, Senator Collins, for convening this really important
hearing. Thank you to the three of you for the great work you
do in this field. I appreciate the focus that we have already
heard today on the social determinants of health. You have all
covered it in one way or the other. Senator Sullivan of Alaska
and I have introduced legislation that would set up a series of
grants to communities to better integrate health care services
and social services. Dr. Cooke, I wanted to--because you have
raised this in a couple of different ways in testimony and
answers to questions.
I wanted to ask you your advice on how to structure the
kind of programing necessary to link together social services,
whether it be nutritional services, housing services, job
training services, and health care services. Is that better off
housed on the social service side, better off housed on the
health care side, better off done by third parties that are
bringing everybody together in one communal table? Have you
found any way that this works better?
Dr. Cooke. I would say all the above. Students from Yale
just recently published a report on public health funding, and
that is one of the things that they looked at, is kind of
thinking outside the box and not just funding health
departments and nonprofit health centers, but actually funding
the entire community through coalitions. And I think it takes
the community all working together across the sectors to really
address those underlying social determinants of health.
There is a model called ROSC, Recovery Oriented Systems of
Care, and it looks at the unique factors within each unique
community, because every community is different, it looks
different, and needs--has different needs. And it allows that
community to figure out what is keeping people down. What is
keeping people from being healthy and well and having purpose
and meaning in their life.
Allows the cross-sector coalition to develop strategies and
definitions that the entire community can get behind and then
start developing programs across those different sectors to
surround people with all the help that they need to enter into
recovery whenever they are ready. Hope that answers your
question.
Senator Murphy. It does. I think that the importance you
place on flexibility and recognizing that every community is
different is important. Dr. Harris, I want to talk to you about
the impact that gun violence has on life expectancy. The data I
have seen is fairly remarkable. Nationally, the total life
expectancy loss due to firearms was about 2.5 years. As you
would imagine, that is a very different number for white
Americans, about 2.2 years versus Black Americans 4.1 years.
And it strikes me that while that data is relative to the gun
violence death itself, the leading cause of death today for
African-American young men, 15 to 24.
To the Chief's point, the trauma of being exposed to gun
violence, especially at an early age, also must have an impact
on life expectancy, given that we know those early traumas lead
you into riskier behaviors later in life. So just wanted to get
a sense of how much research is being done on the impact of gun
violence, both at the rate of death itself, but also the trauma
involved in living in violent neighborhoods and how much that
factors into this national conversation about life expectancy.
Ms. Harris. Thank you for that question. There sort of
needs to be a two part answer to this. In the report, we were
focused on, what was causing the rise in mortality--and there
is significant evidence showing that states that have looser
gun laws and more guns have higher rates of suicide and deaths,
as you said, especially among young adults for whom that is one
of the leading causes. To the U.S., however, the increase to
access to firearms we found did not really explain the rise in
mortality because other cause, other means of suicide, for
example, were contributing more deaths, like suffocation, for
example. However it goes without saying that when there is
greater access to firearms, the deaths that we were examining
of mortality in this report are higher as well as deaths due to
violence.
Now, so that is one part. The second point is the access to
firearms is clearly an important contributor to violent death
rates. And as you said, there has been a lot of new research
around the nature of the victim and the perpetrator and how
these experiences affect them. But the exposure of family
members, neighbors in ways in which crime and violence is
higher. And the one thing that we have found is going back to
record the importance of communities, which is something that
everyone has been sort of talking about.
We think that one of the reasons that we have an increase
in cardiometabolic deaths, for example, is due to the
neighborhoods in which people live. People who live in unsafe
neighborhoods with high crime are--don't have access to open
spaces to exercise and can't enjoy a lifestyle that will help
them keep their weight down and avoid obesity. They don't live
in neighborhoods where they can walk around the corner to the
grocery store and get fresh foods and fruits.
It is a--it is a very important problem that the research
is only now beginning to address because, now for a while
really--the surveys didn't really include questions about guns
and guns in the household and being a victim or witnessing a
violent crime. So I think that the future is going to be able
to provide a lot of answers along those lines.
Senator Murphy. Very quickly. I take your point that it
maybe is not attributed to the recent decline in life
expectancy rates likely because it has been for a very long
time a significant contributor to the rate of death in many of
our communities, in particular communities of color. So thank
you very much, Mr. Chairman.
The Chairman. Thank you.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman, and thank you
for the hearing today and the focus on these disparities. We
have some startling statistics in my state, I would say they
are alarming. When you look to the mortality rates of American
Indians, Alaska native persons aged 20 to 29 years, it is 10.5
times higher. Alaska Native, American Indian persons aged
between 30, 39, 11.6 times higher. And that of those in the 40
to 49, 8.3 times higher compared to their non-Hispanic white
counterparts. They are really troubling. And this was before
COVID as well but when you account for these disparities and
you notice where we have those that are perhaps the most
vulnerable, it is for Alaska native males and those aged 22 to
49.
As I have looked through this report prepared by the
National Academy of Sciences, and again, I apologize, I am only
looking at a summary. But I look at the trends. In all cases of
mortality among males and females and the rates, the thing that
I find most striking is we have good maps in the lower 48, the
continental United States, but we don't have Alaska and Hawaii.
And recognizing that our numbers in Alaska are perhaps so
disproportionate when we are looking to the disparity.
I want to ask, and I don't know whether this goes to you,
Dr. Harris or to you, Dr. Cooke, am I just not looking at the
full report here? Was--were Alaska and Hawaii included, and we
just have failed to put them on the map? There are on the map
of their own because of the awful statistics. But can somebody
address that, and then I want to get back to some of the issues
that contribute to these disparities.
Ms. Harris. I can address that first in terms of the report
and I am so glad you asked this question because the data show
exactly what you said that death rates are highest among Alaska
native and Native Americans. The reason that you don't see them
in the summary is because the data quality was not there for us
to include with the other groups over the entire period that we
examined, which was 1990 to the 2017.
But the quality of the data are getting better, the
reporting of the deaths coming from the various states, and so
we do identify several places in the report. You know, how
high? Very, very high the risks are of mortality for these
reasons. And if I could just quickly add, especially in
response to what Senator Murphy talked about, I want to really
raise the alarm for what is happening to young adults.
As you commented, the young adults 25 to 44 are a very high
risk here. And we see this going into the future. They have
experienced the greatest increases in drug overdose deaths, as
well as suicide, as well as the cardiometabolic deaths. I will
stop there.
Senator Murkowski. Dr. Cooke, did you want to comment on
that?
Dr. Cooke. No, I agree with Ms. Harris.
Senator Murkowski. Okay. I just want to acknowledge, and
again when we think about health disparities, so many of the
other contributing factors that are at play. When we are
talking about rural Alaska, in many places is extremely rural.
You have over 80 percent of your communities that are not
connected by road. You have got small, small communities where
really in terms of economic opportunity, it is very, very
limited. And you have got kind of a clash between a subsistence
lifestyle and being able to get everything on your smartphone
and find out what is going on in Los Angeles and New York and
feeling like you are being left out of what is happening with
the world.
I think we are seeing some indicators, again, as you have
suggested, that it is amongst young men who are looking at
perhaps their surrounding or their life and are choosing
whether it is drugs, alcohol, suicide, the worst, of course,
but also we are seeing that reflected in the high levels of
diabetes or health outcomes there related so often to--what we
are seeing is a change in diet, moving from a healthy
subsistence lifestyle to one that is contributing to increased
diabetes, perhaps cancer, liver disease, kidney disease.
I haven't really framed a question there other than to just
share my thanks to the Committee for shining a light on this. I
am talking about Alaska Natives today, but we know that
American Indians in so many parts of this country today are
faced with the same disparities. And it is an issue where we
are directing a lot of resources finally to the overall health
and well-being of native people.
But I think we have so much territory that we have to
address that it is going to be a real challenge for us to meet
the need. And if we are not all concerned about what we are
seeing with young people, particularly our young native men--we
have all got to be working on this together, so thank you, Mr.
Chairman.
The Chairman. Thank you, Senator Murkowski. I recall, I may
be wrong on this, but in the Pine Ridge Reservation in South
Dakota, the life expectancy there is something like it is in
Guatemala. I mean, it is really just unbelievably low. I
believe Senator Braun is returning, but--it is not the case?
Why isn't--Senator Collins, if you would like to make your
closing statement now, that would be appropriate.
Senator Collins. Okay. I want to express my deep
appreciation to all of our witnesses today. And Chief, I want
to encourage you to continue the work that you are doing in
your county and indeed throughout Maine and throughout New
England to educate people about substance abuse, to help take
away the stigma of getting help, and to assist families in
recognizing when they have a problem in their own family. I
think that is a huge issue. Dr. Cooke, I want to thank you for
the hard work you are doing each day. I am going to submit a
question for the record to you about the increase in suicides
in rural America. In the State of Maine, we have not been
immune from that increase, and our most rural counties have the
highest suicide rates.
That may speak to poverty, to feeling disconnected, to
isolation, to higher rates of substance abuse. But I am going
to be very interested in hearing your thoughts on what we can
do to get physicians, primary care physicians to incorporate in
an annual physical or any kind of visit, a mental well-being
check. I think that is really important. And Doctor, I also
want to thank you for the research that you have done. It has
helped to inform this hearing and helps us ensure, Dr. Harris,
that the work that we do going forward is informed by the best
possible data that we can get. I think that is absolutely
critical.
I will have some additional questions for the record, but I
did want to take this opportunity to thank each of you for the
absolutely critical contributions that you are making to help
us understand the social determinants of good health and also
to assist us in figuring out policies that will help address
everything from drug abuse and substance disorders to the
increase in suicides that I find so troubling. Thank you.
The Chairman. Well, thank you, Senator Collins. And let me
thank our wonderful panelists for their remarks today. As I
mentioned earlier, I think our goal is to try to create a
society in which our people live long, healthy, happy, and
productive lives.
Clearly, I think we have got to focus on issues as to why
we are behind many other countries with lower income and
working class people now in many cases are seeing a decline in
their life expectancy. And what Government policy we can bring
about to radically change that situation.
Thank you very much for the work that all of you were doing
and for helping us shed some light on this serious crisis.
Thanks to Members of the Committee who have been here. And with
that, I adjourn the meeting.
ADDITIONAL MATERIAL
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
QUESTIONS AND ANSWERS
Response by Kathleen Mullan Harris to questions of Senator Casey
senator casey
Question 1. In your testimony, you note that the reversal of
declining mortality rates initially began among younger white women and
men living outside large metropolitan areas, but eventually spread to
most racial and ethnic groups and most geographic areas.
Have there been efforts to evaluate how these outcomes correspond
with geographic areas and employment in industries that have been
impacted by trade? And if so, what does that research show?
Answer 1. Our report reviewed literature on geographic areas
impacted by trade more so than industries per se. In general, research
indicates that trade liberalization policies and increasing import
exposure are associated with higher death rates due to drug overdose
and suicide mainly among Whites. For example, research by Author et al.
(2019) found that the average decade-level rise in import exposure
induced an additional 64.4 male relative to female deaths per 100,000
population per decade. Furthermore, manufacturing trade shocks were
found to cause significant increases in male mortality due to drug and
alcohol poisoning, HIV/AIDS, and homicide. Increased trade tends to
result in worker layoffs, plant closings and reduced wages.
Author, D.H., Dorn, D., and Hanson, G.H. (2019). When work
disappears: Manufacturing decline and the falling marriage
market value of young men. American Economic Review: Insights,
1, 2, 161-178.
If the Senator or his staff would like to speak with Author for
more details or estimates, we can provide the connection.
Below is the relevant text from the Academies Working-Age Mortality
report on this topic, p. 367:
Taking advantage of differential exposures to trade
liberalization due to Congress's granting of Permanent Normal
Trade Relations (PNTR) to China in 2000, Pierce and Schott
(2016) found an increase in mortality due to ``deaths of
despair.'' Counties in the 75th percentile of exposure to PNTR
had a 0.42-0.63 higher suicide mortality rate per 100,000
population compared with those in the 25th percentile,
accounting for 4-6 percent of the average age-adjusted suicide
mortality rate across counties. Likewise, shifting a county
from the 25th to the 75th percentile of exposure to PNTR was
associated with an almost 30 percent higher mortality rate from
accidental poisonings, which include drug overdoses. This
increase in drug-related mortality was observed across a large
portion of the working-age population (most age bins in the 20-
54 age group). Importantly, this association was observed only
among Whites, consistent with the notion that non-Whites are
less affected by job loss (see Chapter 8). Similarly, focusing
on young adults ages 18-39, Author, Dorn, and Hanson (2019)
found an increase in mortality due to increased import
exposure. According to these authors, the average decade-level
rise in import exposure induced an additional 64.4 male
relative to female deaths per 100,000 population (of each
gender) per decade (Author, Dorn, and Hanson, 2019).
Furthermore, manufacturing trade shocks were found to cause
significant increases in male mortality due to drug and alcohol
poisoning, HIV/AIDS, and homicide (Author, Dorn, and Hanson,
2019).
Question 2. I was pleased to see that one of the Committee's policy
recommendations for addressing the rise in working age mortality was
for the 12 states that have not expanded Medicaid under the Affordable
Care Act to do so. My state has benefited enormously from Medicaid
expansion, which is why I aggressively defended that part of the heath
care law during the 2017 repeal efforts.
Given the report's findings on the benefits of Medicaid expansion:
Question 2(a). What do you believe the report's findings on
mortality rates would be like had Medicaid expansion never been signed
into law?
Answer 2(a). Research by Miller and colleagues in 2019 indicated
Medicaid expansion has resulted in a 9.4 percent reduction of mortality
over 4 years. Thus, if Medicaid expansion had never been signed into
law, mortality rates would have been 9 percent higher over the first 4
years of Medicaid expansion. See quote from Miller's paper below.
Question 2(b). How do you believe a repeal of Medicaid expansion
would impact our Nation's mortality rates moving forward?
Answer 2(b). Given Miller's finding above, repeal would result in a
9 percent increase in mortality over 4 years (mortality remains higher
in non-expansion states, thus, deaths averted due to expansion will
increase with a repeal). See quote below from Miller's paper.
``Our analysis provides new evidence that expanded Medicaid
coverage reduces mortality rates among low-income adults. If we
assume that similarly sized mortality reductions would have
occurred in the non-expansion states, our estimates suggest
that approximately 15,600 deaths could have been averted if the
ACA expansions were adopted nationwide as originally intended
by the ACA.''
``Our results therefore indicate that approximately 4,800 fewer
deaths occurred per year among this population due to Medicaid
expansion, or roughly 19,200 fewer deaths over the first 4
years alone.''
Miller, S., Altekruse, S., Johnson, N., and Wherry, L.R.
(2019). Medicaid and Mortality: New Evidence from Linked Survey
and Administrative Data. Working Paper No. 26081. Cambridge,
MA: National Bureau of Economic Research.
If the Senator or his staff would like to speak with Miller for
more details or estimates, we can provide the connection.
Below is the relevant text from the Academies Working-Age Mortality
report on this topic, p. 382:
Medicaid expansion has been associated with a roughly 9 percent
reduction in all-cause mortality among working-age adults
exposed to the policy change; this effect appears to be growing
with time and is estimated to be saving the lives of thousands
of working-age Americans each year (Miller et al., 2019).
Another study found that expansion states have experienced a 6
percent reduction in opioid overdose deaths and an 11 percent
reduction in heroin-related deaths (Kravitz-Wirtz et al.,
2020). Individuals in states that expanded Medicaid coverage
also have experienced better health outcomes relative to those
in states that deferred expansion (Antonisse et al., 2018). In
a study comparing Medicaid expansion states (Kentucky and
Arkansas) with a nonexpansion state (Texas), expansion was
associated with a $337 per capita reduction in annual out-of-
pocket spending, significant increases in preventive health
visits, and a 23 percent increase in the proportion of
respondents who described their health as ``excellent''
(Sommers et al., 2017).
______
Response by Robert MacKenzie to questions of Senator Casey
senator casey
Question 1. Like Maine, my own State of Pennsylvania made
significant progress in addressing opioid use disorder prior to the
pandemic, only to see many of those gains reversed during the COVID-19
pandemic. Although I hope that we do not experience another, similar
pandemic during my lifetime, what do you feel are the ``lessons
learned'' from the pandemic for SUD treatment efforts, and what do you
feel we need to do differently next time to ensure that our gains
against substance use disorder are not erased?
Answer 1. SUD is a disease of isolation. With COVID-19 we were
forced to isolate and it had an immediate impact on those suffering
with SUD. The opposite of addiction is connection. Whatever gains we
had made pre-pandemic were severely impacted and those connections were
lost, and in turn, lives were lost. Many services that had been
available were no longer possible as in-person treatment and meetings
were non-existent or changed to an on-line platform. Many of those
suffering with SUD did not have the ability to have online resources. I
believe it is vital for organizations to have contingency plans to keep
in-person meetings and/or to update infrastructure as so space can
accommodate for social distancing and updated HVAC systems updated with
filtration systems in order to eliminate airborne pathogens. Outdoor
meetings are contingent alternatives where possible which many sites
have adopted.
Having a media program prepared to educate communities the need to
watch out for one another, specifically one that are suffering from SUD
as so loved once and affected others can check on or check in with
those at risk during times of isolation. We use old cell phones for
domestic violence victims and maybe there is an option to extend that
to those at risk as so there is connection. Make and/or increase the
availability of Naloxone to the public.
I believe it is vital for those agencies giving treatment, such as
a Vivitrol injection (a medication that is utilized to prevent relapse,
typically from opioid use disorder) have a back-up plan or alternate
site that is available to provide such injections if they are not able
to continue in times, such as a pandemic. It is my understanding that
pharmacists were a potential option to continue the treatment but some
state laws prohibited them from doing so.
Question 2. Thank you for your efforts to reduce stigma related to
SUD as a way of improving access to treatment. As you are aware, this
stigma is firmly rooted within many organizations and communities, and
can be difficult to dispel. What advice do you have for public
officials, community activists and others who would also like to work
to reduce the stigma associated with this condition?
Answer 2. I have done an estimated 100 or more talks on SUD,
focusing on stigma reduction and have received positive feedback 100
percent of the time. I do not say this to gloat or make it sound as
though I am a great speaker. I believe it is a combination of things
that have contributed to the success of these talks.
Having those speak who are in professions such as physicians, law
enforcement executives, political heads and others whom are passionate
about SUD as these officials already have established credibility with
the audience.
The audience must be educated of SUD being a disease. For those in
the audience that may not feel as though SUD has affected them
directly, I discuss the impact of SUD to our society, in lives lost but
also as to the billions of dollars it costs us each year. (I typically
break the costs down nationally, to a community level and to an
individual taxpayer costs.) I get great feedback on this. With regard
to lives lost, I use national stats but I also use statewide and local
statistics on OD deaths.
Having those speakers, such as myself who have had loved ones
suffering from SUD or have lost a loved one to an OD are very powerful
as it makes it real and that it can happen to anyone.
One of the most powerful additions to speaking engagements is
bringing in someone who is in recovery that is willing to share their
story and answer questions. When the audience has the opportunity to
hear from someone that is open to share their journey, which is
typically a very dark place, but to see how far they have come and how
recovery is possible gives the audience that sense of hope and that
recovery is possible. This really helps reduce stigma.
Having a call to action and asking that the audience members to be
part of the solution. Reduce stigma by talking to loved ones and
friends, taking Naloxone class, (which I typically have one at the end
of the program), asking them to encourage others to participate in
similar forums as we need to work together to make a difference and
save lives.
Calling on civic organizations such as local Rotary Clubs, Lyons
Clubs, Kiwanis Clubs, etc. . . All of these organizations typically
want to help better the lives of the communities they serve and would
love to be involved.
Always invite the media, both broadcast and print. Media outlets
always look for local stories and when organizations invite them in it
not only gets the story out to the communities, it reduces stigma as
their viewers and readers see good organizations working on initiatives
that were not generally talked about due to stigma.
In my experience the more people that are educated and exposed to
those in recovery makes a significant reduction of stigma. Once you
reduce stigma and educate how community members can be involved it
truly prepares your communities to be recovery ready.
______
[Whereupon, at 11:10 a.m., the hearing was adjourned.]
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